Direct Payment Form

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Direct Payment Form

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DORMANT ACCOUNT RELEASE FORM
DIRECT PAYMENT
A U T H O R I Z A T I O N
A G R E E M E N T
F O R
E L E C T R O N I C
F U N D S
T R A N S F E R
AUTOMATED CLEARING HOUSE (ACH) CREDIT/DEPOSIT TO IBMSECU FROM ANOTHER FINANCIAL INSTITUTION.
Use of this form:
 To credit/deposit funds into your IBMSECU account from another financial institution.
 The credit/deposit cannot exceed $5,000.00; higher amounts must be processed as incoming wire transfers.
Remember:
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Cancellations or changes to this agreement must be in writing and require five (5) days advance notice.
For verification, a voided check from the other institution may be attached to this completed form.
You can use this form for monthly, weekly or “One Time Only” transactions.
Delivering a signed copy to the Credit Union in person, by mail or fax authorizes Direct Payments.
I hereby authorize IBM Southeast Employees’ Credit Union (IBMSECU) to initiate debit entries to my account at the financial institution listed
below. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.
Financial Institution:
Branch:
Routing Number:
Account Number:
Type of Account (Please check one):
Checking
Money Market
Savings
Please attach a voided check from the other financial institution to this signed agreement.
Amount to Debit: $
Date to Debit:
Recurrence (Please check one):
Monthly
Action (Please check one):
Start
Weekly
Skip
One Time Only
Change
Stop
Distribute funds to IBMSECU account number:
This authorization is to remain in full force and effect until IBM Southeast Employees’ Credit Union (IBMSECU) has received written notification
from me of its termination, in such time and in such manner as to afford IBMSECU a reasonable opportunity to act on it.
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Direct Payments scheduled on weekends or holidays will take place on the next business day. The Credit Union will not be liable for any fees or charges assessed by
other financial institutions.
The information supplied on this agreement must be accurate and current. You will be liable for any losses incurred as a result of incorrect information. Immediately
notify the Credit Union in writing of any changes involving account number, frequency or amount.
In the event funds are unavailable at the other financial institution, the Credit Union will not re-initiate the debit entry until the next scheduled transfer. It is your
responsibility to make other arrangements to pay any loan that was not performed for that transfer frequency. The Credit Union is not obligated to furnish you with
a notice in the event the transfer was not completed, nor is the Credit Union liable for any fees or charges assessed by other financial institutions.
Member Name:
Member Number:
Member Signature:
Daytime Phone Number:
Date:
Email Address:
Please Fax this completed form to Electronic Processing at 561.982.4776. For assistance, please contact us at
800.873.5100 or [email protected]
FOR CREDIT UNION USE ONLY
Operator Name / Number:
Date / Time Received:
Extension:
Processed By Operator Name / Number:
IBMSECU – Federally Insured by NCUA – Direct Payment Form – July 2016 – Page 1 of 1